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CRNA vs. Anesthesiologist Surgery Help
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Is this a hospital or surgery center?
I don't work with CRNAs anymore, but my previous groups always accommodated patients with this request if we knew in advance. Sometimes we could accommodate day of surgery. I would find out who is the chair of the anesthesia group and talk with him/her.
I don't blame you. If I don't know and can't handpick my CRNA I'd rather have a doc.
I'm assuming they are describing the Anesthesia Care Team model (ACT) that is supported by the American Society of Anesthesiologists and is the most common method of anesthesia care in the US. In that model an anesthesiologists medically directs several CRNAs (or AAs) at once similar to how an ICU has 1 attending physician covering multiple patients at the same time, except it's most often at a ratio of between 2:1 to 4:1. That is also how residency programs function with one attending covering 2 residents at the same time. If that is the case your anesthesiologist will meet with you preoperatively and come up with an anesthetic plan, order you some meds, be present for induction, check back periodically, and be present for emergence and then check on you again in the recovery room.
I could be wrong and maybe the are describing some sort of model where there is a CRNA that occasionally gives a break in a case being done solely by the MD but that gets kinda weird on the billing side of things depending on the state. But when the surgeon says present for induction and extubation they seem to be describing ACT.
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deleted480308
It depends on why you are asking about the size of the stink....
If you are worried about being rude in the context of the world at large. Who cares. You are the customer and you set your expectations which they can either meet or call your bluff, then you back down or go elsewhere
If you are doing it at your hospital...then it gets more complicated as people gossip and you could anger the nurses as a group
If you are worried about being rude in the context of the world at large. Who cares. You are the customer and you set your expectations which they can either meet or call your bluff, then you back down or go elsewhere
If you are doing it at your hospital...then it gets more complicated as people gossip and you could anger the nurses as a group
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Agree. They are not the only place that conducts surgery. Demand it from the surgeon if it means that much to you. If they can't accommodate, they will be missing your payment as you go somewhere else.
And the part about angering nurses, you are wise beyond your medical age. You will anger nurses, it's just a matter of how many. Some are fantastic, some are very difficult. Some are miserable at baseline.
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Depending on where it is happening, it's likely you have to tell more than just the surgeon that cause they may not be running the scheduling. You likely have to talk to someone on anesthesiology side since they may not have the staffing to have an attending cover you 1 on 1
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Demand physician administered anesthesia. It is your choice. Make a big deal out of it. Being there during intubation and extubation isn't the same thing.
I supervise a CRNA and I can't get her to tape the eyes before intubation - ever. I tell her all the time. I kow actually have to tape the eyes.
The point is, even if there is no difference, you should get what you want.
I supervise a CRNA and I can't get her to tape the eyes before intubation - ever. I tell her all the time. I kow actually have to tape the eyes.
The point is, even if there is no difference, you should get what you want.
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When I'm on the phone with customer support, I always asked to be transferred to a US based agent. Sometimes I get blow back from the receiving agent but I remind them that I'm saving their jobs.
Ask your surgeon to request physician only administered anesthesia and follow-up with their scheduler and the anesthesia group.
Ask your surgeon to request physician only administered anesthesia and follow-up with their scheduler and the anesthesia group.
Obviously you should get what you want, but in many places you couldn't get MD only care within 500-1000 miles of where you are located. There are strong geographic differences. If someone requested that of us, I'd tell them there is nowhere in our state they could get it (at least that I am aware of). If you want to fly somewhere else to have your surgery, just be ready to do that.
As to your CRNA that won't tape eyes, that seems more like a problem of a CRNA that is a hospital employee and not your employee. Get their boss that signs the paychecks to discuss it with them and the tune may change.
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They have thousands of graduates every year. Get her fired and pick up someone who's not stupid.
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Might I add a counterpoint. If said Crna won't tape the eyes before incubation, has she ever had a complication? If she does hold her accountable and she should be fire for dereliction from standard practice.
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Well done.
No place that has anesthesiologists shou,d ever refuse the right of a pt to request to have an anesthesiologist present for the entire procedure.
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Uhh... you work with all anesthesiologists right?
We run a really tight ship doing 4+ cases supervision and that simply ain't happening...
Unless this is a VIP and we get creative with the pain schedule or someone is willing to come in while on vacation.
We put friends and family with a good crna and make frequent visits. Luckily this is easy since we employ our crnas and the bad ones get the boot.
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I recommend you find a way.
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...
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This is disturbing to me.
You are too good to take care of pts yourself one at a time?
And the pts that request an anesthesiologist are "probably going to be a pain in the ass".
I thought the old guys that raped our specialty were bad.
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I tried to edit since I realized I kind of made your point for you in the last line of my post and wanted to explain. I was looking at it from my standpoint and not of the average patient. After I explain how our system works and the ability of our crnas, patients understand they are getting a safe anesthetic. I would let my crnas do my anesthetic without hesitation and my partners have in the past.
Let's put ego aside a second and remember a monkey could propsuxtube. That's not what differentiates the nurses and docs. If you think you're doing this great service for patients by sitting on your stool in autopilot mode, keep telling yourself that.
But come to my neck of the woods and see how many anesthesiologists you can recruit. It has nothing to do with me thinking I'm "too good to take care of patients one at a time" and that's a pretty lame allegation.
And yes, if a patient would absolutely refuse to let my competent crna be in the room without me after I explain our way of doing things, they would be a pain in the ass and could go somewhere else.
Sounds like you would definitely be getting surgery elsewhere
could not be done in our hospital and if a patient wanted it, I'd recommend they purchase a plane ticket since they would not be in driving distance of a place that could do it for them.
Now if somebody wants me to be the one that intubates their class 1 airway, that's fine. I'm standing there anyway and do that often enough anyway. But if they care that I am the one that turns the dial on the sevo from 3 to 2 for their ASA 1 self having a lumbar lami, well i have other patients that are just as important to attend to. But like I said, I support their right to fly somewhere else to have their surgery.
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We have a balance of cases we do as MDs, but there is a limited pool. If someone wants me to do their case, but there is a heart and an fragile aneurysm clipping going on, I cant do it. But if they are flexible with schedule, I can.
I love when a patient makes a surgeon reschedule so one of the MDs can be in a case. Feels like a good turnabout when the surgeon has to do a case at 330 because that is when I am available.
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I love when a patient makes a surgeon reschedule so one of the MDs can be in a case. Feels like a good turnabout when the surgeon has to do a case at 330 because that is when I am available.
Sent from my iPad using SDN mobile app
The first thing I think reading through this thread is how interesting the dynamic will get if the AANA gets their way with "collaborative" models. Docs will likely have their pick of practice locales and the nurses will have to fill what's left since they won't be cheaper in that scenario. Or, do hospitals save money by paying the nurses less than the docs?
You will see more "doc only" hospitals where patients can always have doc only anesthesia. Many surgeons will take their cases to these hospitals because they will get better, more consistent anesthesia care.
You will see more "doc only" hospitals where patients can always have doc only anesthesia. Many surgeons will take their cases to these hospitals because they will get better, more consistent anesthesia care.
The AANA talks a good game "we are cheaper "
Yet when push comes to shove.
Crna's in the trenches i have close relationships with. They all will not work a full call schedule for anything less than 300k.
Why should they accept less? They already making 180k and working 36 hours with no calls and no weekends.
That daytime MD 7-3 makes only 220-250k.
The spread difference between Md and crna isn't great when comparing apple to apples (working hours and calls and nights and weekends)
Yet when push comes to shove.
Crna's in the trenches i have close relationships with. They all will not work a full call schedule for anything less than 300k.
Why should they accept less? They already making 180k and working 36 hours with no calls and no weekends.
That daytime MD 7-3 makes only 220-250k.
The spread difference between Md and crna isn't great when comparing apple to apples (working hours and calls and nights and weekends)
They're not much cheaper and come with a significant knowledge/skill gap.
Very little bang for their buck from a hospital perspective.
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Send them to me.
well I'm not paying their airfare for them
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It saddens me to think a patient would be considered a PITA for politely requesting an anesthesiologist. I don't understand that. I'm paying the same whether there is an anesthesiologist taking care of me throughout or the "collaborative" model where I have no clue who is involved and have to obtain medical records to learn it took 3 different anesthesiologists (2 who I never even met) and a CRNA for a short elective surgery planned over a month in advance. I like knowing that the anesthesiologist I meet prior to surgery is the one taking care of me. If it makes me a PITA for requesting an anesthesiologist, I hate that, but so be it.
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I guess I'm a PITA then because I've requested doc only anesthesia.
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This is real-world ACT private practice. Done properly and appropriately, ACT is perfectly safe and acceptable for most, if not all, procedures.
Those of you in high-volume practices (and I'm talking tens of thousands of cases a year) understand this. If you want an anesthesiologist to personally do your case, that's certainly possible, but you better arrange it in advance in our practice - and I'm not talking the day before. We start our day with over 100 anesthetists and 35 or more docs. We have patients occasionally show up on the day of surgery wanting MD-only anesthesia. That's simply not going to happen. Every single anesthesiologist in our practice is committed to specific responsibilities in our practice every day, and those assignments are scheduled a couple months in advance. Our surgeons know the way we practice. They're perfectly comfortable with it. We are a tertiary referral center, 100% private practice. Our anesthesiologists do all regional, blocks, and central lines. EVERY patient has an anesthesiologist present at induction and emergence, and as often, and for as long as necessary, as needed throughout the case. That idiotic study from one of the ivory tower centers that claims that 1:4 medical direction is not physically possible has zero idea of what they're talking about, because it can be and is being done every day in many practices.
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deleted171991
Respectfully, I disagree. I work in an ACT model, and I don't believe a physician can be there for induction and emergence (and definitely not for the all key moments of a case), even with "just" 1:3 coverage. Even being present for every induction and emergence is a big deal in any fast-paced setting with unhealthy patients preopped on the day of surgery. Maybe in a culture where anesthetists are required to call the attending to the room before inducing or extubating, or where turnover is 30-40 minutes and the cases are long. Even then, running around all day long is physically exhausting. I tend to believe that any coverage beyond 1:2 is basically midlevel anesthesia with physician firefighters and/or cookbook medicine.
I still have to see one single practice (even academic one) where things are done 100% by the book, meaning that all seven TEFRA requirements are met for every case. Meaning (among others) that the attending develops the plan and the anesthetist follows it to the letter (as a resident would), or that the attending is physically in the room for every key moment of a case (e.g. peritoneal insufflation for a laparoscopic case, or turning a patient prone etc.) Or just simply every emergence. It's just not possible in the real world. Not only that, but it's frowned upon by most anesthetists, who don't like to feel "micromanaged". Given the fact that most practices can't afford pissing off their anesthetists, one can guess what really happens (not the BS that's sold to patients). There are parts of the country where even SRNAs will occasionally give attendings attitude. (That's an entirely different story, but there is an entire generation of young militant CRNAs that have been raised and taught by the old militant CRNAs - who were much fewer and less militant.)
So, on topic, there is no better care than a good solo anesthesiologist (who works solo every day). It's a dying breed, at least in my neck of woods (except for cardiac or day docs). The ACT model is good enough, but it's not the golden standard of quality care. Yes, there are some great anesthetists out there, who know what they don't know, ask for help even after 30 years of practice, and follow attending instructions to the letter (and would be great even solo). But they are the exception. Unfortunately, as more and more attendings are forced to practice in an ACT model and don't get enough/any solo time, we are reaching the point where even a smart patient won't want a doc anymore, because the doc will be rusty.
tl;dr: The best care is probably a solo anesthesiologist in a MD-only practice. Good luck finding one in certain parts of the country.
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Different perspectives, different experiences. I have no problem with MD anesthesia in the places that are able to do that, but an increasing number of places simply aren't set up to do it that way.
You don't need to be there from the moment the patient rolls in the room until the incision is made. Similarly, you don't need to be in the room at the time the last staple goes in until the patient rolls out to PACU. How frequently a doc checks on the progress of a case is a function of the type and length of the case, as well as the patient's condition. A 20-30 minute lap chole probably doesn't require an intra-op check at all. An OB hemorrhage might require near continuous attendance of the anesthesiologist (maybe more than one). We are fortunate to be able to staff accordingly. We aren't so tight that we don't have extra pairs of hands available at a moment's notice.
Our anesthetic plan is, for the most part, MAC, general, or regional. Since all our blocks and regional are done by the doc, that's never an argument. Unless there are specific issues, there's no need for the anesthesiologist to give a laundry list of what to do in a given case. Our OB practice runs like clockwork. We have a number of specific procedure protocols (outpatient total joints in particular) where each case is done almost identically. (standardization is not a bad thing) There's no need to call the anesthesiologist for changes in vital signs that are easily managed, but calling with sustained and/or significant changes is a given. Our newer anesthetists are "micro-managed" to a certain extent until they are well-oriented.
It depends on how much time you think you need to spend at induction, emergence, etc., how you define your "key moments", as well as how much you trust and depend on your anesthetists to do the right thing. We don't have arguments about technique. It's understood that our practice is ACT with an anesthesiologist in charge, yet that relationship is quite collegial and professional, and there is much mutual respect for the roles that all of us play. We happily hire both AAs and CRNAs, but the chain of command is crystal-clear from day one. Those who don't understand that likely aren't hired in the first place or won't last long if they are.
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deleted171991
Then let me tell you the newest East Coast (AMC) model I've seen: anesthesiologist candidates for a job get interviewed also by CRNAs, who can have even veto power over their hiring. Plus this is not like most of team medicine (e.g. ICU), where the plan is discussed in detail, and approved by the physician first. The system is not built for that. The system is built for greed and making the most money, not for the best quality of care. Meaning that while the big decisions are left to the physician, many small ones belong to the anesthetist. Some anesthetists frown on anything that means more work and/or changes their cookbook medicine recipe, e.g. not using versed in elderly or keeping their BP high enough. When one has to phrase one's requests as "what do you think about..." versus "please do this or that" it's not medical direction, it's supervision or worse. When one's employment is conditional on not pissing off the CRNAs (or other nurses), it's not true medical direction. Plus, unless there is a computerized record in place, most attendings cannot regularly check on the patients' vital signs and the anesthetists (as required by law), unless they run around like headless chicken all day long.
Of course, all of this is highly variable and dependent on local culture. But, in a market where most anesthesiologists are used especially as preop monkeys and firefighters, employers care more and more about keeping their anesthetists (and not anesthesiologists) happy. A good anesthetist gets work much easier than a good anesthesiologist, for the simple reason that there are more jobs for the former. In such places, medical direction is more of a wish than reality.
Thank god ive never run into this arrangement.
What's interesting is, I stay in touch with some of the CRNAs from my old group- the non militant ones. They are great people and I enjoyed working with them, just not some of the others. Anyway, they are very concerned for their futures, I guess they have some internal data that shows a glut of anesthetists by 2020; AAs are displacing them from jobs, apparently the bigger groups there are preferentially hiring AAs. It sounds like one group in town started hiring AAs and it's catching on. They feel threatened and insecure.
They are convinced their pay is heading into advanced practice nursing territory, 100k or so.
It's just interesting to me to hear their perspectives since so often we believe the opposite.
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I am there for every induction and emergence in an ACT model. All the spinals, epidurals and lines (outside of I.V.s obviously) are done by the anesthesiologists for any case. I don't think CRNAs should be doing spinals, epidurals, central lines, etc. Even A lines are questionable for CRNAs.
Doctors are largely at fault for the MILITANT CRNA that is COMMON nowadays because they let them do all the lines, epidurals, spinals, induction, emergence, etc while sitting in the coffee room. At that point, the CRNA rightfully feels there is no need for an anesthesiologist.
It kind've sucks because the CRNAs are more militant than ever and act like the anesthesiologist is TOTALLY unneeded and useless. This is particularly true for YOUNGER anesthesiologists who are just out from residency for a few years. This is why Anesthesiologist should NEVER have allowed CRNAs to do epidurals, spinals, lines, etc because that just makes them appear unneeded when the CRNA literally does everything.
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JWK said...
"Those of you in high-volume practices (and I'm talking tens of thousands of cases a year) understand this. If you want an anesthesiologist to personally do your case, that's certainly possible, but you better arrange it in advance in our practice - and I'm not talking the day before. We start our day with over 100 anesthetists and 35 or more docs. We have patients occasionally show up on the day of surgerywanting MD-only anesthesia. That's simply not going to happen. Every single anesthesiologist in our practice is committed to specific responsibilities in our practice every day, and those assignments arescheduled a couple months in advance. Our surgeons know the way we practice. They're perfectlycomfortable with it. We are a tertiary referral center, 100% private practice. Our anesthesiologists do all regional, blocks, and central lines. EVERY patient has an anesthesiologist present at induction andemergence, and as often, and for as long as necessary, as needed throughout the case. That idioticstudy from one of the ivory tower centers that claims that 1:4 medical direction is not physicallypossible has zero idea of what they're talking about, because it can be and is being done every day inmany practices."
We have 160+ anesthesiologists and just short of 300 CRNAs.
From personally having pts ask for MD only, mostly from the coasts, I can say that we never entertain that question. Our answer is some variation of, "People come, often long distances, to us because we are good, and the ACT is how we are good, so if you ask us to change, it will only derail why we are good."
"Those of you in high-volume practices (and I'm talking tens of thousands of cases a year) understand this. If you want an anesthesiologist to personally do your case, that's certainly possible, but you better arrange it in advance in our practice - and I'm not talking the day before. We start our day with over 100 anesthetists and 35 or more docs. We have patients occasionally show up on the day of surgerywanting MD-only anesthesia. That's simply not going to happen. Every single anesthesiologist in our practice is committed to specific responsibilities in our practice every day, and those assignments arescheduled a couple months in advance. Our surgeons know the way we practice. They're perfectlycomfortable with it. We are a tertiary referral center, 100% private practice. Our anesthesiologists do all regional, blocks, and central lines. EVERY patient has an anesthesiologist present at induction andemergence, and as often, and for as long as necessary, as needed throughout the case. That idioticstudy from one of the ivory tower centers that claims that 1:4 medical direction is not physicallypossible has zero idea of what they're talking about, because it can be and is being done every day inmany practices."
We have 160+ anesthesiologists and just short of 300 CRNAs.
From personally having pts ask for MD only, mostly from the coasts, I can say that we never entertain that question. Our answer is some variation of, "People come, often long distances, to us because we are good, and the ACT is how we are good, so if you ask us to change, it will only derail why we are good."
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deleted171991
I am sure they are right, too. There are market forces at work against all of us. The problem is that we too will get paid APRN salaries in the future (when compared on an hourly basis), the same way primary care docs don't make much more than their midlevels (when adjusted to the amount of work and responsibility).
Let's dissect the $300K community anesthesiologist salary with Q5 overnight call, even without late days. That's 6 calls/month, about 1/3 without the consecutive day off (Fri or Sat call). So that's 23 days x 8 hours + 6 call days x another 16 hours - 4 post-call days x 8 hours = 248 hours/month, so about 3000/year. Minus 1/8th of that (taken as vacation and fewer and fewer holidays) makes about 2600 hours/year. That's about $115/hour, i.e. CRNA salary, except that CRNAs would get an overtime/call bonus. 😉
And people wonder why I have no respect for medical students who look forward to getting into anesthesiology today.
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Will get worse if CRNAs get independence because there will be a downward pressure on CRNA salaries due to their oversupply.
How the hell did docs let the CRNAs do spinals/epidurals/regional/lines/etc? I still can't get around how that happened.
You don't see cardiologists teaching their nurses how to do a cath or GI docs showing their nurses how to do a scope.
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An NP's Journey to Credentialing for Colonoscopy
https://www.linkedin.com/in/dr-jordan-hopchik-crnp-a62ab18b/
"Dr." Jordan Hopchik, CRNP
"On a few occasions, the department head has asked me to oversee GI fellows with colonoscopy training so he could perform administrative duties."
I thought I've heard of people agitating for midlevels to start doing caths as well but I can't find anything online.
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Good god, that is absurd. Nurses simply don't realize that technical skills are not what makes a physician.
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I guess this is how the CRNA stuff started 20-30 years ago.
GI might go down the same path in 30 years if they keep that up.
Once they give up the "technical skill" of colonoscopy, they will lose their higher salaries due to nurses being able to do it.
Once a function appears to be ABLE TO BE DONE BY A NURSE with EQUAL COMPETENCE, that function inherently becomes the DOMAIN of the nurse.
Its hard to reverse that perception by saying "well the technical skill doesn't matter because I have more education". That doesn't fly.
So when the GI nurses can do endoscopies and colonoscopies with polyp removal JUST AS WELL as the physician, the physician will argue that he/she should get paid 3 times the nurse salary because he/she also writes some PPI or something or "knows the indications for these scopes better than a nurse"?
Never going to happen.
I think you just haven't seen well run practices then. We meet TEFRA for 100% of cases. I am electronically time stamp signatured in to case during induction and emergence. Can't fake it. It is possible in the real world. Is it tiring some days? Sure. But I get paid to work, not sit on my ass. You just work in a poor setting with CRNAs that aren't your employees.
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deleted171991
I was talking about 1:3+ settings. The ones I have worked in have been mostly 1:2, and I personally always meet TEFRA requirements.
Where I was wrong is that I assumed that TEFRA requirements include being there for the "key moments" (of the procedure, not of the anesthetic plan), because that's how the TEFRA compliance statement appears on some of the paper records. There is no such requirement. It's just a synonym for the most demanding aspects of the anesthesia plan, not the entire surgery. One is not required to be present for the most risky parts of the surgery, although it's always good practice (not only in OB).
So let me withdraw my previous statement, because that's the part I could not see happening for high ratio coverage.
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I hope with all my might that a nurse will never touch me for anything but the simplest nursing task... (and i'll throw in a good percentage of incompetent MDs for good measure ) of course this doesn't apply to SDNers since we are all second to none.
Sometimes i wonder if it wouldn't be more merciful to equip ER docs with shotguns when i see how people are treated.
Sometimes i wonder if it wouldn't be more merciful to equip ER docs with shotguns when i see how people are treated.
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That is f*cked up.
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Why do people on this site feel the need to attack others that are basically on the same side as them?
This is unnecessary.
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Another example of unnecessary attacks on your compatriots!
Why not have a discussion without insults?
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So I'm not so delusional to think that I am any better at this profession than anyone else on this site. I just have a bit more experience than many here and I wish to share it. You can accept that as rhetoric or as experience, I don't care other than I believe that there is no better anesthetic than an anesthetic delivery solely by an anesthesiologist. However, I am not so delusional to think that this is possible in our country. There just isn't enough of us. And I don't disagree with anyone that claims that there are some fantastic nurses or AA's doing this job as well. I have worked with some ( an AA actually taught me how to do an axillary block). And yes I would let them perform my anesthestic in a pinch but by no means would I take them over a personally chosen anesthesiologist.
So what I'm getting at is that if "we" want to maintain the physician basis of this specialty then we need to come together and support as much physician delivered anesthesia as we can possibly manage. I get it that some practices can't manage even the slightest bit of this. That saddens me but I understand the constraints. I also wonder if this is financially driven more than anything. Don't tell me that you can't recruit physicians when your senior partners are making more than the national average though. This is bullsh*t. If you live in an area that can't support hiring physicians then your cost of living is more than likely extremely lower than the national average and this argument holds no water.
So stop saying that the ACT model is the best. Instead, say it's the best you can do and live with it.
So what I'm getting at is that if "we" want to maintain the physician basis of this specialty then we need to come together and support as much physician delivered anesthesia as we can possibly manage. I get it that some practices can't manage even the slightest bit of this. That saddens me but I understand the constraints. I also wonder if this is financially driven more than anything. Don't tell me that you can't recruit physicians when your senior partners are making more than the national average though. This is bullsh*t. If you live in an area that can't support hiring physicians then your cost of living is more than likely extremely lower than the national average and this argument holds no water.
So stop saying that the ACT model is the best. Instead, say it's the best you can do and live with it.
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- Messages
- 418
- Reaction score
- 457
Agree! If a place can recruit surgeons, it can recruit anesthesiologists. It's all about the money.
I'm not attacking him. He repeatedly points out dislike of his job structure. Not all jobs are like that. Not all ACT practices have physicians supervising CRNAs that are not their employees. He incorrectly feels that by ever having a ratio above 2:1 that you cannot medically direct safely and appropriately and my response to that is that yes you can.
- Joined
- May 17, 2007
- Messages
- 505
- Reaction score
- 193
That's not nice.
I'm guessing you will never be coming to SE Minnesota for surgery on you or any of your family.
But, if you do, because never is a long time, remember this quote.
The way we are set up, MD only cannot happen. We have 265 or so anesthetizing rooms each morning at 0700. We can't spare a Doc to sit a room by themselves.
